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What is a framework?

A framework is a basic structure that helps guide your approach to something. For example, let’s say I want to drive to Sunderland from Sheffield. I haven’t a clue how to do that. And say I don’t have a sat nav device or any other electronic device for that matter. What should I do?

I could get in the car and just drive around. Okay – there is a possibility I will end up getting lost. But if I get onto the main roads and read all the road signs carefully I should be able to find the motorway which will then direct me further. And yes, it might take 2 hours longer than expected – but I could be successful and end up in Sunderland! BUT this method is messy and unstructured and that makes it lengthy, unpredictable and therefore unreliable.

There is a better way – and that is by using a map. With a map – we can get an overview of how to get there and keep that in our minds. That map will help us do the journey in half the time! In this example, the map serves as a framework for our journey. In doing so, the framework (= the map) helps our journey become smooth and structured. In fact, we might even be able to enjoy the ride and admire the scenery. In a similar way, a consultation framework is like a consultation map – it helps with our consultation approach by making the consultation journey smooth and structured. And hopefully even enjoy that journey.

The other advantage of a framework is that it provides a reference structure that you can fall back on. For instance, if you get all nervous and flustered: take a deep breath, revisit that CSA framework in your mind. Identify where you got flustered and where you need to start back from. Then you can determine what steps needs to happen to get to the end. Just like the you would do if you accidentally took the wrong turn during your Sheffield to Sunderland trip. You would pull up somewhere safe, take a breather, get your map out (the framework), identify where you are and determine how to get back on track.

Why have a framework or model?

This video explains why models (or frameworks – the same thing), and why they are important.

In summary…

They provide structure to the consultation – for both you and the patient.

They ensure you do a comprehensive enquiry

They help you do a time-efficient job.

In this video, Matt talks about consultation models and in particular Flannagan’s model. It’s a 20 minute video.

Ram's 5+5 CSA consultation method

I developed this framework because I kept seeing GP trainees repeatedly run out of time during practice CSA sessions. Many were actually doing very well with the the cases but they were losing marks for running out of time and missing a whole chunk of say ‘the management’. An examiner cannot give you marks for Clinical Management if you ran out of time to do it. They cannot second guess what you would have done – not matter how well you did the Data Gathering bit or how nice you were as a doctor. So, ‘Ram’s 5+5 method’ aims to help you remember that time is limited and you’ve got to move on and get to a final closing point.

The concept is simple.

FIRST 5 MINS: Spend it on DATA GATHERING

The presenting complaint – allow the patient to talk.

Follow with a good enough history(including Red Flags, Family Hx & Social Hx).

Where it is natural to do so, explore the patient’s Ideas, Concerns and Expectations (ICE).

Again, naturally explore the Psycho-Social-Occupational (PSO) impact of the problem on the patient’s life.

Follow on with a focused examination.

LAST 5 MINS: Spend it on EXPLANATION, PLANNING & CLOSURE

Share your thoughts – go through the examination findings explain the diagnosisand what made you come to that conclusion.

Explore what the patient thinks and feels in response to what you have said (and address any ICE issues).

Then formulate a JOINT management plan – remember the effective use of resources (i.e. not to over or under investigate/prescribe/refer).

And finally safety net and follow up if needs be.

Both of these sections (the first and second 5 minutes) offer an opportunity for you to provide evidence for all three marking areas – Data Gathering, Clinical Management and Interpersonal Skills. Don’t just think the first 5 mins on Data Gathering is solely about Data Gathering and the second 5 minutes on Clinical Management.

For example, in the first 5 minutes:

You will take a history (which gives you marks for Data Gathering).

You will do an examination (also Data Gathering)

But the way you ask those questions and the way you approach the examination will be provide marks for Interpersonal Skills.

In the second 5 minutes…

You may have remembered something you forgot to ask earlier on (providing more marks for Data Gathering).

You then explain the diagnosis (and the way you explain it providing marks for Interpersonal Skills).

You then explain the Management Plan (and if it sounds clinically good, you get marks for Clinical Management, and the way you explain it gives marks for Interpersonal Skills).

You may then notice the patient isn’t that happy with your management plan and you ask why (marks for Data Gathering) and then you modify the plan accordingly (more marks for Interpersonal Skills) as you both then plan a joint management plan.

Want more information on the Ram’s 5+5 Method? See the Downloads section above.

In this clip, Dr Anu & Dr Giam summarise some of the things you need to achieve (which I’ve covered by each of the 5 minutes)

In these clips, Dr Matt Smith and Omar talk about my 5+5 model. Some Trainers, Trainees and TPDs suggest a variation on my model – namely the 6+4 method. In other words, 6 minutes on Data Gathering and 4 minutes on the Explanation, Planning & Closure. That’s fine. Some CSA cases will undoubtedly require more time on the Data Gathering whilst others will need less. The way I see it is the 5+5 model provides a rough idea of time and not a rigidly fixed one. But one thing is for sure: by the 6 minute stage, you definitely need to start thinking about wrapping things up and closing.

Develop your own framework

There are several frameworks out there to help you with the CSA – not just mine. For example, Flannagan’s and Ross’ model – both of which can be found in the Downloads section above. Of course, you don’t have to stick to any of these. You could modify one or combine bits from each to develop a framework that suits your personality and style.

Remember, this is not about making all GP trainees into replicas of one model. You are individual and unique. The frameworks define the content – i.e. what it is that needs to be achieved at the end of the consultation. BUT how you go about achieving those outcomes is entirely up to you. It’s a bit like peeling an orange. You can peel an orange a variety of ways. Some will use their hands. Others will use a knife. Yet others might use a fancy gadget. What really matters is whether the orange is successfully peeled at the end of the day without bruising it. (Can you bruise an orange? Mmmmm…. I’m not sure, but I hope you get my point!)

Now, if you look at all the frameworks you will notice that what they have in common is the content – they all spell out the same sorts of things that need to be covered. The way they differ is in their order or style. And you can do the same too. Please do play around with the different frameworks and develop your own if none of them suit.

But what's the point of a CSA framework when I'm not going to use it after I qualify?

That’s a good question! But who said you have to ditch it after the CSA exam and that you can’t use it in real life GP consultations?

Actually, if you look at qualified GPs, you will see that they all follow a framework. Yes, all of us follow a consultation framework of some sort and each GP will have developed their own version to fit in with their own personality and style. Some GPs may not even realise they are following a model – but they are – because if you watch them repeatedly, you will be able to map out a common structure that they tend to follow.

When we don’t follow a common structure, that is when things often go wrong and the doctor-patient consultation falls down. We all forget to follow our usual consultation now and then (e.g. when we’re in a rush), and we feel it when we do!

For instance, I saw a patient who I actually thought we had a good consultation. It was about whether she should give anti-anxiolytics a go and i subsequently prescribed some. She came to see my colleague and told him she didn’t take them and he asked why. She said she had a friend who became dependent on similar tablets and she was very scared of that and in general didn’t like tablets anyway. And when I thought back, I do remember not particularly exploring her Ideas, Concerns and Expectations. If I had done, then perhaps we could have come up with a better joint management plan like engaging with an anxiety management programme or mindfulness.

So – all GPs use some sort of consultation framework. Many of us use the Skills for Communicating with Patients (Silverman, Kurtz & Draper) model, others use Neighbour’s model and yet others use Tate’s mode. Newer qualified GPs tend to use some variant of the CSA framework that they practised with as a trainee. Therefore do invest time in developing the right CSA framework for you – because it will continue to serve you after qualification and often for life!. And the beauty is that you won’t even realise you are doing or following it – just like the way you no longer have to deeply think about what history or examination to make like the way you used to as a medical student. It becomes a part of you and the process becomes natural as it is internalised.

By the way, I use a combination of Tate’s and the Silverman, Kurtz & Draper model. Why? Because when I did MRCGP, we had to send in 15 video consultations to the RCGP who had video examiners who marked them. Our videos were assessed using a model based on Tate’s & Silverman’s model. Not surprisingly, I followed these models because I knew they would help me get good marks in my MRCGP video assessments. But even after qualification, I continue to loosely follow this model because a) it has become an effortless part of my work-life being (i.e. I no longer have to think about it) and b) it works (i.e. it makes me cover things comprehensively, holistically and in a structured way compared to just jumping in). In other words, it gives me peace of mind.

In summary, invest in your CSA framework – because it will serve the basis of your approach in the rest of your working GP life. The only difference between pre and post CSA is that you can take longer than 10 minutes in the real GP world – what a luxury!

Getting your first minute right - the 'golden' minute

The first minute of ANY encounter (be it a colleague, friend or stranger) is incredibly important because it ‘sets the scene’ for the rest of the interaction. For example, if let’s imagine for a moment that you’re at a shop counter returning an item you’ve bought that you regret buying. If you appear quite dominant in your behaviour and strong in your verbal tone, the shop assistant will either become angry back or anxious/flustered. Neither position is particularly good in terms of helping you. And do you think it is a nice position to put the shop assistant in?

What is a good position is a nice positive joyful interactive encounter between both of you which results in a seamless return of the item. You want to be able to leave the shop and say “That was nice and easy and that person was really helpful.” This example also demonstrates that the way YOU behave in any encounter often affects how the other person behaves. Actually, this is what happened to me the other day when I had to return a twin pack of T shirts that didn’t fit when I got home. The shop assistant and I had a little giggle as I told her about how slim I thought I was until the T shirts told me otherwise! And the exchange was lovely.

Let’s look at another example. Let’s say I am meeting a friend in a cafe and they arrive 30 minutes late. How do you think they will react if I greet them with… “Oh finally, you got here did you”? Do you thing they will be on guard and defensive? And will the rest of out coffee morning be nice and relaxed or edgy and uncomfortable?

The Golden Minute

So, what’s my point? What has this got to do with the doctor-patient encounter?

It means getting the first minute right is really crucialbecause it has a big impact on the rest of the consultation. Actually, everyone talks about the ‘golden minute’ but the research says that the patient’s opening monologue can last anywhere from 30 to 90 seconds. So, please don’t be too rigid about the 1 minute thing.

And the way you behave will affect how the patient behaves and how long they talk and open up. So, if you look like you’re in a rush, a bit too abrupt, a bit arrogant, busy looking at the screen or doing other things – the patient wont open up. Their monologue will last less than 30 seconds and you will get very little information of useful value. But the patient’s monologue is incredibly important to elicit. Why? Well, imagine yourself in a large garden maze and at the starting point you don’t know which way to turn. Wouldn’t it be nice if there was a little arrow just to start you off? And that’s what the patient’s monologue does for you in the consultation. It provides a starting point that provides a bit of guidance for the rest of the consultation.

So, how do you it?

It’s quite simple really. Start of by being quiet but also start off by being yourself. Be nice. Be kind. Be compassionate. Be forgiving. Show that you want to help them. And do all of this with true genuine feeling. Show that you care. You don’t have to do this by talking – do it with your body language, body posture, facial expressions and of course by listening attentively.

Shussshhhhhh......

And after that intiial phase, explore things they say – be curious – because this shows that you are both listening and want to understand. Ask open questions and let the patient speak some more. And of course empathise with true genuine feeling. All of this will help a patient, whatever state they are in, to settle down and talk back to you on the same level that you are talking – i.e. with kindness, compassion and respect. The rest of the interaction is more than likely to become truly collaborative, creative and positive (just like the encounter I had with the store assistant I mentioned earlier). And you’ll get all the information you need to make a reliable working diagnosis and form a safer collaborative management plan. In essence, you’ll end up ‘doing the right thing’.

Don't forget about the narrative

CSA examiners really love it when you approach a consultation in a patient-centred rather than a doctor-centred way. A doctor-centred one is where the doctor asks lots of questions and the patient is just expected to mostly respond and not say too much in between (often called the ‘question-answer’ or ‘tick-box’ approach). This is the way many of us were taught to take a history in medical school.

In a patient-centred approach, the patient is allowed to talk and tell their story. This gradual unfolding of the story is called a narrative approach and it’s important because it helps you build a better and more clearer picture of what’s going on. For instance, the patient might end up telling you something unexpected that will totally change your diagnostic and management plan. Therefore, it is vital we involve patients and allow them to talk freely in the consultation if we want to get a true account of the nature of events that will help make our diagnoses more accurate, prevent mistakes and formulate management plans that are likely to work.

A doctor-centred consultation goes something like this

Doctor: What’s the problem then?

Patient: I’ve got chest pain..

Doctor: Where is it?

Patient: Here (points to chest)

Doctor: And when did it start?

Patient: half an hour ago

Doctor: And is it still there?

Patient: It’s kind of settled a bit.

Doctor: And what’s the pain like?

Patient: I don’t know. Pain is pain I suppose.

Doctor: For example, is it sharp like a needle or is it tight, dull or burning?

Patient: Errm yeah more tight and heavy…

Get the idea?

A patient-centred consultation goes something like this

Patient: Well, I’ve been having them for about a month now and at first I didn’t think much of them. But now, the pain is so tight and heavy that I have to stop walking and take a breather. And the odd thing is that I’m getting weird pains down this arm too (points to left arm). It happened again half an hour ago, and that’s why I came to see you. But it has settled down a bit now.

Doctor: And you said you were worried. What crossed your mind?

Patient: Well my dad had a heart attack in his 40s and I’m now 42 and wondering whether I’m going to end up the same way. And I smoke heavy like he did too.

Doctor: Thank you for that. Now, I need to ask you some specific medical questions. Is that okay?

Patient: Yeah sure doc.

Do you see the difference?

Can you see how you get so much more information if you shut up and let the patient speak more.

And if you ask more open questions rather than closed ones – you get a more fuller story.

And the fuller story tells you whether your need to worry or not. It will reduce the chances of you making a clinical error of judgement than the doctor-centred question-answer method. And that is the most important thing at the end of the day.

And can you see that even from the small snipped about, it doesn’t take longer to do.

And it’s great doing it because no longer will you consult by using asking the same boring mundane parrot fashion questions you have learnt. Instead, you learn to ‘fill in the gaps’ present in the patient’s story told so far.

This ‘story’ that the patient tells is called the patient’s narrative.

Remember, every patient has a different and unique life. Each patient is at the centre of their own stories. So it seems illogical to use the medical school ‘one method fits all’ approach to all patients.

Listen to this story….

The other day, I had a patient with classic migraine. And as we all know, migraines are really horrible. What’s worse is that if the patient’s life is chaotic (stress, not sleeping on time, not eating regularly etc) then it’s likely the migraines will become more recurrent.

Back to the story – I was basically in a bit of a rush, and thought to myself that I will just given her some acute migraine treatment and perhaps some prophylaxis to reduce the frequency of recurrence. Now doesn’t that sound like a clinically okay management plan? And I might have just done that and she might have just nodded in superficial agreement (i.e. not real agreement).

But something inside me told me to slow down and ask her about her lifestyle. She told me how busy life was and then I asked her if she was aware that migraines can be more frequent if our lives are busy, stressful and chaotic. Her eyes opened more widely and I could see she didn’t know this and wanted to talk about it in more detail. Anyway, to cut a long story short we found out that she wasn’t really one for pills and didn’t fancy taking a long term migraine prophylactic drug for the rest of her life. But what she asked was whether she could just have a couple of weeks off to sort some things in her life so that she was sleeping and eating regularly and less stressed out overall. I agreed to her request because it sounded like a fabulous plan.

Can you see how this plan was jointly made and as a result is perfectly tailored to this patient who is then more likely to comply with it compared to the earlier generic plan of ‘acute + long term migraine medication’?

If I had gone with the latter, she probably wouldn’t have taken the longer term medication; this begs the question of why waste all the time and effort in the first place?

And can you see how I could never have second guessed this near perfect management plan without being interested in her and her thoughts?

Isn’t it better just to spend a few more moments on the patient’s narrative so that you can tease out information that will help formulate a management plan that is more likely to work for the patient?

A plan that works for the patient leads to a happier patient. A happier patient means a happier family, happier friends, happier work colleagues and so on. And of course happier doctors – as this contribution to people makes us as doctors feel good too. That happier doctor could be you!

The story is everything.

What does all this mean for the CSA?

A CSA framework is simply a structure to guide you. Most CSA frameworks out there look something like this…

Open question/golden minute

ICE

Psychosocial (work, home life, mood)

Confirm drug hx and PMH based on patient information given

Closed questions, Red flags

Examination

Relate to ICE

Discuss diagnosis

Options for treatment

Follow up +- safety net

And this looks like a good ‘guide-map’ for your CSA consultations. Remember that word – guide – in other words, to gently provide a direction for you in the consultation. It’s not there to force you into doing things in a rigid and strict fashion. If it was, it would have been called a protocol!

Therefore, use the consultation frameworks as they are intended to be used – as guides – gently follow their direction – but allow for flexibility. If the patient goes off in another interesting and relevant direction, then be curious, follow them, and when that line of enquiry is over gently come back to the framework, see where you are, and continue.

But the problem is that in the CSA, trainees end up following their favourite CSA framework in a rigid and inflexible manner. And what that results in is a whole series of ‘doctor-patient-question-answer’ interactions. To the CSA examiners, this interaction then starts to look like a survey, a questionnaire or even interrogation – no actual story develops. If the patient decides to say something sensitive, they are quickly shut down by such doctors simply because it would mess up the sequence in their favourite consultation framework. They say something like ‘we’ll come back to that later’ just because they want to carry on rigidly in the sequence of the framework rather than the naturally following the story.

Remember what we said – it is the story that provides the accurate picture. If the patient’s story could be likened to a big jigsaw puzzle, doing the traditional “doctor-centred question-answer” model provides just a one jigsaw piece at a time. However, following the narrative results in a small bunch of jigsaw pieces at a time thus enabling you to make a clearer picture in quicker time.

So, what I am saying is: YES – use a CSA framework to help structure your CSA consultations. But don’t use them so rigidly. Allow a bit of flexiblity depending on the patient, their problem and the context. So, a patient whose husband has just died, yes – be flexible, go gentle, see where the patient takes you, and follow the patient (keeping the CSA framework parked in your mind to come back to when it is more appropriate to do so). Yet with the patient who rambles on and on about this that and the other, then you might want to follow a CSA framework with less flexibility in order to ensure that you have carried out a comprehensive enquiry in a structured way in the limited time given. Follow your heart as well as your mind. Be curious. Be interested. Be open. Show compassion and empathy. Be flexible. Be relaxed. Be yourself. And if things turn out to be irrelevant to the current enquiry, then come back to the framework.

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